Cries for help

A baby's crying is one of the most heart- rending, yet most profoundly vexing sounds. While it is a baby's main way of communicating, it can be the last straw for exasperated, sleep-deprived and especially new parents. Continual crying is the biggest reason for parents and carers to pick up and shake babies. But shaking is dangerous, as it can easily damage small brains, causing long-term disability and even death.

The relative fragility of children under 18 months, along with their vulnerability because of their dependence and the tremendous stress that a newborn can cause parents, are being highlighted by child protection charity NSPCC in a new training pack, Fragile: Handle with Care.

The pack, comprising a video, trainer's guide and a reader with papers on research and practice, is aimed at health staff, especially those regularly in contact with pregnant women and families with babies: midwives, health visitors, GPs, community and hospital paediatricians, paediatric nurses, obstetricians and accident and emergency doctors and nurses.

"Health is often seen as peripheral to child protection," says Evender Harran, NSPCC project co-ordinator. "But health professionals are well placed to identify carers who are finding it difficult to cope, and to intervene prior to situations escalating - largely because they provide a universal, non-stigmatising service."

Harran says that the charity embarked on the project after its research uncovered a training gap. "We sent questionnaires to primary and secondary health care and found that child protection training was sporadic. Health professionals felt they lacked knowledge about the vulnerability of babies; others felt it was hard to raise the issue of child protection with parents at what was meant to be a happy time. They didn't know about the law, about the impact of social circumstances, or cultural needs. It confirmed the need for a training resource, which included a social model that considers the socio-economics, like housing, income and support from the family, as well as a medical model of diagnosis and treatment."

Janet Polnay, the named doctor for child protection at Nottingham City hospital NHS trust, agrees that child protection "tends to be rather left out" as far as training goes. Medical schools are inconsistent in their approach, she says, with much depending on the interests of individual consultants. "Where doctors are very motivated, they will have their own slide library (and other training resources) but, in other hospitals where there are other priorities, there may be no resources. It's very variable."

Some stark facts bear out the need for child protection awareness among staff working with babies: children under one are two-and-a-half times more likely to be on the child protection register than any other age group; they are five times more likely to be murdered than at any other age; and they are more likely to be killed by members of their own family. And it is not only lethal violence that is of concern: research shows that children under 12 months are more often than not regularly hit, with more than half being smacked at least weekly.

The new video starts with a documentary, in which child health experts outline issues and concerns, such as shaken baby syndrome, and risk factors or signs. These may include very young parents, a child not growing well, post-natal depression or stress, a previously abused child in the family, domestic violence or a father who is not the biological parent. Three scenarios then follow, with actors playing health workers who meet a depressed mother, teenage parents and a couple where domestic violence is hinted at.

"The scenarios were very realistic and not patronising," says Pippa Shillington, a health visitor in Lewisham, south London, who is involved in training colleagues. "Teenage pregnancy is a real problem in Lewisham. Young parents with a premature baby are very vulnerable."

Terence Stephenson, professor of child health at Nottingham University, sees using scenarios as a smart way of engaging doctors. "The case scenarios bring it to life," he says. "In the past, we've tended to use circulars that end up in the bin." But for Stephenson, the big obstacle is a lack of time and money. "If you want to train doctors to recognise child protection," he says, "the limiting factor is covering the service while you take people out for training."

Acknowledging these constraints, the NSPCC has taken a modular approach to design of the pack. "It's very flexible," comments Margaret Lynch, who chairs the child protection committee of the Royal College of Paediatrics and Child Health. "You could show just one scenario and initiate a lunchtime discussion with junior doctors."

Shillington concurs. "Devoting a lot of time would be problematic, but you could dip in." She intends to use it immediately in parents' antenatal classes to raise the dangers of shaking babies. But the pack has also set her thinking strategically. "Now we're meant to be working in partnership, I thought maybe we ought to be linking up with police," she says. "Health visitors don't necessarily know about domestic violence that's occurring."

This will be music to Lynch's ears. "The idea of the pack is to try and prevent abuse, so you have to make links between child abuse and domestic violence," she says. "This is all about making links - not just with other professions but also between the parent and the baby, or the mother's mental health and the baby. So you're not staying in your compartment and just looking at the baby's health but at the whole family, and then moving on and being aware of what other services are available for them."

The pack stresses that health visitors and midwives are in a position to make an "holistic" assessment and advise on support and information parents can get from friends and family or local voluntary and statutory organisations, as well as from the health visiting and midwifery staff. American research suggests that ante-natal and early home visiting by nurses can halve the incidence of child abuse and neglect, although such visits have dropped by 20% in England since 1990.

Naomi Eisenstadt, chief executive of the government's Sure Start initiative, who appears in the video, says: "The kind of support services we're describing aren't just about preventing bad things happening. They are also about parent support that makes good things happen, that makes happy, healthy babies, that makes happy, healthy children."

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